International data allow policymakers to compare the performance of their own health care system with those of other countries. In this chartbook, we use data collected by the Organization for Economic Cooperation and Development (OECD) to compare health care systems and performance in nine industrialized countries Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, the United Kingdom, and the United States. Whenever possible, we also present the median value of all 30 members of the OECD.

The chart book is organized into eleven sections

Total Spending

Public and Private Health Care Financing

Health Spending by Type of Service

Hospitals

Long-Term Care

Physicians

Nursing

Pharmaceuticals

Medical Procedures Involving Sophisticated Technology

Non-Medical Determinants of Health

Mortality

9

Methods

The source for most of the data is the OECD. Data were sent to each country for review, and any additional sources are noted on individual charts. Every effort is made to standardize the comparisons, but countries inevitably differ in their definitions of terms and how they collect data. The most recent year is used whenever possible, but when it is not available for a specific country, data from earlier years are substituted, with the substitution noted on the chart. All health spending was adjusted to U.S. dollars using purchasing power parities, a common method of adjusting for cost-of-living differences. Because of definitional and data concerns, the comparisons should be seen as guides to relative orders of magnitude rather than as indicators of precise differences. Detailed methodological notes and definitions are provided in the appendix.

10

Total Spending

In 2003, per capita spending for all health care services ranged from a high of 5,635 in the United States to a low of 1,886 in New Zealand. The median for all 30 OECD countries was 2,280. The United States spent 15 percent of GDP on health care services, compared with 8.4 percent in the median OECD country. Most of the countries had an increase in health spending as a percentage of GDP between 1993 and 2003. Over the last 20 years, the United States had the fastest average annual growth rate of real health spending per capita and Germany had the slowest rate.

Public and Private Health Care Financing

Universal publicly financed health insurance coverage exists in Australia, Canada, France, Japan, New Zealand, and the United Kingdom. In Germany and the Netherlands, every citizen has access to public coverage, but individuals with higher incomes may opt for private coverage instead. Among all OECD countries, the United States had the highest level of health financing from public sources in 2003. This is surprising because only one-quarter of all Americans have publicly financed health insurance. The United States spent nearly 25 times more than the median OECD country on private health care spending (excluding out-of-pocket spending). In the United States, private health insurance coverage is the most common source of health insurance, but other countries primarily use private insurance as a supplement to public insurance coverage. Out-of-pocket spending per capita in the United States was almost twice as high as in the median OECD country.

11

Health Spending by Type of Service

In 2003, the median OECD country spent 40 percent on hospitals, 15 percent on physicians, 16 percent on pharmaceuticals, and 10 percent on long-term institutional health care and home health care. The remainder was spent on multiple health care services, including dentists and durable medical equipment, as well as biomedical research and development.

Hospitals

In 2003, the United States spent the most per capita on hospital services. Canada and Japan spent the least per capita on hospital services. An alternative measure is inpatient acute care spending per day the United States spent two times the median OECD country and five times more than Japan.

The United States falls below the median OECD country, and often at the bottom of the nine countries, in certain service utilization measures hospital discharges, average length of stay for acute care, average length of stay for acute myocardial infarction, average length of stay for normal delivery, and average annual number of acute care days, and the number of acute care beds. Germany and Japan were consistently above the median OECD country on these utilization measures. The United States had the highest number of health employees per 1,000 acute care days, and more than twice that of Germany, the country with the least number of health employees per acute care day.

12

Long-Term Care

Canada had the most long-term care beds per 1,000 people over the age of 65 in 2003, while the United Kingdom had the fewest. Canada and the United States spent the most on long-term institutional care per capita, and the United States spent the most on home health care per capita in 2003. France spent the least on long-term institutional care per capita, and France and Japan spent the least on home health care per capita. Germany experienced fastest growth rate in long-term institutional health care spending per capita, and had the fastest growth rate in home health care spending per capita.

Physicians

The United States spent almost three times the median OECD country on physician services per capita in 2003. In the last decade, the United States and Australia experienced the most rapid increase in average annual growth rate in real spending on physician services, while Japan had a decrease in the spending growth rate. The number of physician visits per capita is relatively similar in all nine of the countries except for Japan, which had many more physician visits. The nine countries also had similar numbers of physicians. The United Kingdom and the United States experienced the fastest increase in practicing physicians per 1,000 people between 1993 and 2003 while Canada saw a decrease.

13

Nursing

In 2003, the Netherlands had the most nurses per 1,000 people, while France had the least. The United States had below the OECD median number of nurses per 1,000 people. The United Kingdom had almost four times the number of nurses per acute care bed as France.

Pharmaceuticals

The United States spent more than two times the OECD median per capita on pharmaceuticals in 2003. The Netherlands spent the least on pharmaceuticals per capita among the nine countries. Spending for pharmaceuticals increased the fastest between 1993 and 2003, at a rate of approximately 9 percent in both Australia and the United States. Japan only had a 1.1 percent average annual growth rate in real pharmaceutical spending.

14

Medical Procedures Involving Sophisticated Technology

The diffusion of medical technology occurs at different rates across the nine countries. For example, the number of magnetic resonance imagers (MRIs) and computer tomography (CT) units per capita varied considerably. Japan had the most MRIs and CTs, with almost 13 times the number of MRIs per capita as France and nearly 16 times the number of CT units per capita as the United Kingdom in 2003. Japan, Germany, and the United States consistently have the most technology available, while France, New Zealand, and the United Kingdom tend to have the least.

A comparison of utilization rates for specific procedures is confounded by differences in the incidence of disease and disease classification, among other factors. However, there are striking differences in utilization rates for certain procedures. For example, Germany had 794 cardiac catheterizations procedures per 100,000 people while the United Kingdom had only 14. The United States performed the most percutaneous transluminal coronary angioplasty procedures, coronary bypass procedures, and knee replacement procedures per 100,000 people in 2003. Japan and the United States had the highest number of patients undergoing dialysis. France, New Zealand, the Netherlands, and the United Kingdom had consistently lower rates of these procedures.

15

Non-Medical Determinants of Health

About one-third of the population in the Netherlands and Japan were daily tobacco smokers in 2003. Canada and the United States had the lowest rates of daily tobacco smoking. Australia, Canada, and the United States have experienced the largest drop in smoking rates over the last 20 years. Alcohol consumption is highest in France and lowest in Canada. A large proportion of the United States population is obese. Japan had the lowest obesity prevalence. Japan also had the smallest change in obesity rates between 1993 and 2003, while the United Kingdom had experienced the largest increase in obesity rates.

16

Mortality

Measuring health outcomes is extremely difficult as all the widely available indicators are crude proxies and not very sensitive to changes in health care financing and delivery.

In 2003, men lived an average of 5.6 fewer years than women. Japan maintained the longest life expectancy at birth for men and women. The United States had the shortest life expectancy at birth for men and women. Over the last twenty years, Japanese women and Australian men had the largest gain in life expectancy among the nine OECD countries. The Netherlands had the smallest increase in life expectancy for both men and women.

At the age of 65, Japanese men and women had the longest life expectancy. Japanese women had the largest increase in life expectancy at the age of 65 over the past 20 years, and the United States had the smallest increase. Australian men had the largest increase in life expectancy at age of 65 while men in the Netherlands had the smallest increase.

Mortality rates are influenced by many factors in addition to health care. One indicator that is potentially sensitive to health care intervention is the five-year survival rate for certain diseases. Breast cancer survival rates in the United States are slightly higher than those in Australia, France, and England (United Kingdom data not available). Breast cancer screening rates are similar in Canada, Australia, the United States, and England, but lower in New Zealand. Kidney transplant five-year survival rate was highest in Canada, and lowest in the United States.

17

Summary

In 2003, the United States continued the trend of spending the most per capita on health care services among the 30 OECD countries. The United States also spent the greatest proportion of total spending on health care services. International comparisons reveal three areas that are partially responsible for the higher spending in the United States hospital spending per acute care day, spending on physician services, and prices of pharmaceuticals. In each of these three categories, the United States spent double the amount of the next highest country. Resources and utilization rates in the United States are low especially for acute care days and other utilization measures.

The United States is also a clear outlier in insurance coverage. While the other eight countries have achieved nearly universal health insurance coverage, approximately 40 million people in the United States are estimated to be uninsured in 2005. The United States spent the most on publicly financed and privately financed health insurance and also paid the most out-of-pocket. On one important outcome measure, longevity, the United States was consistently at or near the bottom among the nine countries.

Cost-sharing Medicare reimburses 75 percent of the scheduled fee for private inpatient services and 85 percent to 100 percent of ambulatory services. Doctors are free to charge above the scheduled fee, or they can treat patients for the cost of the subsidy and bill the government directly, with no patient charge (referred to as bulk billing). There is a bulk-billing incentive scheme and almost 75 percent of medical services are bulk billed. Prescription pharmaceuticals have a patient copayment. Out-of-pocket payments account for 19.7 percent of total health expenditures.

Safety nets A Medicare safety net for non-inpatient services, and a separate pharmaceutical safety net, protect against high out-of-pocket costs.

How are revenues generated?

National Health Insurance (Medicare) Compulsory national health insurance administered by the Australian (federal) government. National health insurance is funded by a mixture of general tax revenue, a 1.5 percent levy on taxable income (accounting for 17.3 percent of federal outlays on health) and fees paid by patients. Additionally, a Medicare Levy Surcharge applies to high-income individuals without private health insurance for hospital coverage. Government funds almost 70 percent of total health expenditures (46 percent federal and 22 percent state/local).

Private Insurance Mainly not-for-profit mutual insurers cover the gap between Medicare benefits and schedule fees for inpatient services. Doctors may bill above the scheduled fee. Private insurers also cover private hospital accommodations, choice of specialists, and avoidance of queues for elective surgery. Private insurance covers 49 percent of the population (43 percent have hospital cover with nearly all of these also having ancillary cover, whilst 6 percent of the population are covered for ancillary services only). Expenditure by private health insurance funds accounts for 7.1 percent of total health expenditure. Through a rebate, 30 percent of private health insurance premiums are paid by the Australian government. The rebate increases to 35 percent for people aged 65 to 69 years, and to 40 percent for those aged 70 years and over. How is the delivery system organized? Physicians Primary care physicians act as gatekeepers. Physicians are generally reimbursed by a fee-for-service system. The government sets the fee schedules, but these are not maximum prices. Hospitals Mostly public, run by the states. The states pay for public hospitals with Australian government assistance negotiated via five yearly agreements. Physicians in public hospitals are either salaried (but may have private practices and fee-for-service income) or paid on a per-session basis. Government The Australian government has control over hospital benefits, pharmaceuticals, and medical services. States are charged with operating public hospitals and regulating all hospitals, nursing homes, and community-based general services. How are costs controlled? Australia controls its health care costs through a combination of global hospital budgets, fee schedules, limited diffusion of technology, copayments for pharmaceuticals, and waiting lists. The government also restricts the number of medical students and Medicare-licensed providers. 96The Canadian Health Care System

Who is covered?

Coverage is universal for eligible residents of Canada.

What is covered?

Services Through the Canada Health Act, the federal government requires that provincial and territorial health insurance plans cover all medically necessary physician and hospital services to qualify for full federal transfers. The federal government is also directly responsible for health care services for specific groups, including the Royal Canadian Mounted Police, serving members of the armed forces, eligible veterans, First Nations individuals living on reserves, the Inuit, and inmates in federal penitentiaries.

Supplementary benefits Provincial and territorial governments also provide supplementary benefits for certain groups such as senior citizens and social assistance recipients. Benefits include services such as prescription drugs, dental care, home care, aids to independent living, and ambulance services.

Cost-sharing No cost-sharing for insured physician and hospital services. However, there may be charges for other, non-insured services.

How are revenues generated?

Publicly funded health care Public health insurance plans are administered by the provinces/territories and generally funded by general taxation. Three provinces charge additional health care premiums. Federal transfers to provinces/territories are tied to population and other factors and are conditional on meeting the principles of the Canada Health Act. Public funding accounts for approximately 70 percent of total health expenditures.

Privately funded health care Many Canadians have supplemental private insurance coverage through group plans, which extend the range of insured services to include vision and dental care, prescription

drugs, rehabilitation services, private care nursing, and private rooms in hospitals. Private health expenditures represent approximately 30 percent of total health expenditures. How is the delivery system organized? Physicians Most physicians are in group or private practices and remunerated on a fee-for-service basis. However, many Canadian physicians receive some payment for clinical care through alternative public payment plans. In 200203, about 17.5 percent of total clinical payments to physicians were made through these types of arrangements. Provincial/territorial medical associations generally negotiate the fee schedule for insured services with provincial/territorial health ministries. Physicians must opt out of the public system of payment to have the right to charge their own rates for medically necessary services. Nurses Most nurses are primarily employed either in hospitals or by community health care organizations, including home care and public health services. Nurses are generally paid salaries negotiated between their unions and their employers. Other health professionals Dentists, optometrists, therapists, psychologists, pharmacists, and public health inspectors may be employed or self-employed, and are generally paid salaries negotiated between their unions and their employers. Hospitals Mainly public and private non-profit hospitals that operate under annual, global budgets. Budgets are negotiated with the provincial/territorial ministries of health or regional health authority, with some fee-for-service payment. Government Provincial/territorial governments have the authority to regulate health providers. However, they typically delegate control over physicians and other providers to professional colleges, which license providers and set standards for practice. How are costs controlled? Cost-control measures include mandatory annual global budgets for hospitals/health regions, negotiated fee schedules for health care providers, formularies for public drug plans and limits on the diffusion of technology. 97The German Health Care System

Who is covered?

Up to the determined income level, every employee must enroll with any of the Sickness Insurance Funds (SIFs) offering the same comprehensive health care coverage. Individuals above that income level have the right to opt out and obtain private coverage instead.

Sickness Insurance Funds There are approximately 249 SIFsautonomous, not-for-profit, nongovernmental, although regulated by the government, bodies. They are funded by compulsory payroll contributions averaging 14.2 percent of wages, equally shared by employers and employees. SIFs cover approximately 88 percent of the population. Dependents are covered through the primary SIF enrollee. While the unemployed continue to contribute to the SIF proportionate to their unemployment entitlements, health care costs incurred by welfare recipients, asylum seekers, and the homeless, are financed through general revenues. In 1998, SIFs accounted for 81 percent of health care expenditures.

How is the delivery system organized? Physicians General practitioners (GPs) have no formal gatekeeping function. However, in 1994, special GP contracts required all SIFs to offer at least one model of GP gatekeeping to their enrollees. All physicians in the outpatient sector are paid on a fee-for-service basis. Representatives of the SIFs negotiate with the regional associations of physicians to determine aggregate payments. Hospitals Hospitals are mainly non-profit, both private and public. They are staffed with salaried doctors. Senior doctors may also treat privately insured patients on a fee-for-service basis. Representatives of the SIFs negotiate payment rates with hospitals at the regional level. A new payment system based on diagnosis-related group per-admission payments was introduced in 2004. Government The German government delegates regulation to the self-governing corporatist bodies of both the SIFs and the medical providers associations. However, given lack of efficacy and compliance, the government is increasingly willing to replace the self-regulating system and delegate more purchasing powers to the SIFs. How are costs controlled? The government imposes sector-wide budgets for physician and hospital services. Budget ceilings for prescription drugs were abolished in early 2001, leading to an unprecedented increase of expenditures for pharmaceuticals and increasing financial strain on the SIFs. Health care reforms in the 90s included increased competition among sickness funds the introduction of a per-admission hospital payment system the control of physician supply and moderate cost-sharing provisions. 98The Dutch Health Care System

Who is covered?

Public and private coverage is nearly universal.

What is covered?

Normal, necessary medical care.

The Sickness Funds Act (ZFW) compulsorily insures people whose annual salary falls below a statutory ceiling and all recipients of social security benefits, up to age 65. This covers about 65 percent of the population.

Other health insurance schemes cover various categories of civil servants, accounting for around 5 percent of the population.

Those not covered by the ZFW or schemes for civil servants can obtain private health insurance coverage on a voluntary basis. Approximately 30 percent of the population is privately insured.

Beginning January 1, 2006, all citizens will have compulsory basic insurance, the distinction between private and public insurance will no longer apply. Insurers will be obliged to accept patients for this basic insurance, and will need to compete on price and quality.

Long-term care and high-cost treatments are covered for all by the Exceptional Medical Expenses Act (AWBZ).

Public universal insurance for exceptional medical expenses, including long-term care, mental health, etc. Compulsory social health insurance for the low income, voluntary private health insurance for the high income, and voluntary supplemental insurance for all. Ambulatory care is provided by independent GPs, who mostly work in private practices. Almost all Dutch citizens have regular GPs, who handle 95 percent of health problems within primary care practices. Patients with more complex problems are referred to other care providers.

Cost-sharing Each insurance arrangement, including public sickness funds and private plans, require some form of cost-sharing, including copayments and deductibles. All those insured by the ZFW incur a 20 percent co-insurance rate. How are revenues generated? The AWBZ is funded by premiums paid by people covered under the scheme, local taxes, and government subsidies. Contributions through the tax system to the national government provide funding for all national health insurance schemes. A portion of employed individuals income is deducted by employers and paid to the national health insurance funds. The percentage withheld corresponds to level of income. Those insured by the ZWF pay an additional non-income-related premium. Local taxation Local taxes are a supplementary source of funding for most health insurance arrangements. Central government grants and payments A series of grants are available for the purchase of services not covered by entitlement programs. These include services earmarked for future inclusion in the entitlement package, as well as innovative forms of care. The central government also uses a portion of general revenues to supplement funding of entitlement programs. Out-of-pocket expenditures account for approximately 9 percent of total health care costs. Four percent is covered by copayments under the AWBZ, 2 percent by copayments and deductibles under the ZFW, and 3 percent by direct payments for private complementary or supplementary insurance plans. Those covered by private insurance pay a nominal premium, averaging 1,277 (USD) in 2003. Beginning in 200, all patients will have compulsory basic insurance with a nominal premium of about 1,3001,400 (USD) and an income-related premium add-on. Private insurance Private insurance coverage is funded out of premiums and cost sharing. Those who opt for private coverage are required to pay solidarity contributions to the national health insurance scheme. A portion of each individuals premium accounts for this contribution. Private insurance packages are available as stand-alone and supplementary coverage. 99The Dutch Health Care System (continued)

How is the delivery system organized?

Physicians Physicians practice under national contracts negotiated by health insurers and providers representative organizations. GPs are paid on a capitation basis for patients insured under the ZFW and on a fee-for-service basis for privately insured patients. Beginning in 2006, GPs will receive a capitation payment for each patient on the practice list and a fee per consultation. Additional budgets can be negotiated for extra services, practice nurses, complex locations, etc. Experiments with pay-for-performance quality are underway. Specialists working in hospitals are self-employed, and are paid a capitated amount based on negotiations between insurers and specialists organizations. Some specialists are paid on a fixed income/salaried basis and have contracts with the hospitals. Future payment will be related to a new payment system, Diagnose Treatment Combination (DBC).

Hospitals The majority of hospitals are private and non-profit. Hospital budgets are based on a formula that pays a fixed amount per bed, patient volume, and number of licensed specialists, in addition to other considerations. Additional funds are provided for capital purchases. As of 2000, payments to hospitals are rated according to performance on a number of accessibility indicators. Hospitals that produce fewer inpatient days than agreed with health insurers are paid less, a measure designed to reduce waiting lists. A new payment system, DBC, is currently being introduced, and 10 percent of all medical interventions are now reimbursed on the basis of these DBCs. In some experimental hospitals, 100 percent of all interventions are based on DBCs. It is expected that most future care will be defined under this new system, although there is debate regarding its feasibility.

Government Much of the responsibility for managing the health insurance schemes is handled at the regional level. Thirty-one regional health care offices carry out duties such as contracting with providers, collecting patient contributions, and organizing regional alliances. The national government approves all contracts negotiated between regional councils, insurers, and providers. How are costs controlled? Providers negotiate contracts that dictate the volume of services to be delivered, as well as charges to be assessed to users. These contracts are subject to the approval of the national government, which sets limits on the amounts that doctors, hospitals, and nursing homes can charge. Costs are expected to be increasingly controlled by the new DBC system in which hospitals have to compete on price for specific medical interventions. 100The New Zealand Health Care System

Who is covered?

All New Zealand residents have access to a broad range of health services with substantive government funding.

Cost-sharing Copayments are required for general practitioner (GP) and general practice nurse primary health care services, and non-hospital prescription drugs. Health care is substantially free for children under age 6 and is partially subsidized for most other people depending on age and income. Patient copayments account for 16 percent of health care expenditures (200203).

How are revenues generated?

General taxation Public funding is derived from taxation. It accounts for about 78.3 percent of health care expenditures (200304).

The government sets a global budget annually for publicly funded health services. This is distributed to District Health Boards (DHBs). DHBs provide services at government-owned facilities (about one-half, by value, of all health services) and purchase other services from privately owned providers, such as GPs, most of whom are grouped as Primary Health Organizations (PHOs), disability support services, and community care.

Patient copayments People pay fee-for-service co-payments to GPs and for pharmaceuticals, and for some private hospital or specialist care and adult dental care. In addition, complementary and alternative medicines and therapies are paid for out-of-pocket.

How is the delivery system organized? Physicians GPs act as gatekeepers and are independent, self-employed providers paid through a combination of payment methods fee-for-service with partial government subsidy, mostly capitation funded through PHOs. Consultants (specialists) working for DHBs are salaried but may supplement their salaries through treatment of private patients in private (noncrown) hospitals. Primary Health Organisation The government has injected substantial additional funding into subsidising primary health care to improve access to services. From July 2002 to date, 79 PHOs have been formed under government policy to reduce health disparities and take a population approach to primary health care. Ninety-two percent of the New Zealand population is now enrolled with and receiving care from PHOs. PHOs will have a range of different clinical and non-clinical health practitioners on staff and be funded partly by capitation and partly by fee-for-service. By July 2007, all New Zealanders will be able to receive low cost access to primary health services provided by PHOs. District Health Boards The DHBs (21 in the country) are partly elected by the people of a geographic area and partly appointed by the Minister of Health. They are responsible for determining the health and disability support service needs of the population living in their districts, and planning, providing, and purchasing those services. A boards organization has a funding arm and a service provision arm, operating government-owned hospitals, health centers, and community services. Government New Zealands government has responsibility for legislation, regulation, and general policy matters. It funds 78.3 percent of health care expenditures and owns DHB assets. How are costs controlled? The government sets an annual publicly funded health budget. In addition, New Zealand is shifting from open-ended, fee-for-service arrangements to contracting and funding mechanisms such as capitation. Booking systems are being introduced to replace waiting lists to ensure that elective surgery services are targeted to those people best able to benefit. Early intervention, health promotion, and disease prevention are being emphasized in primary care and by DHBs.About one-third of New Zealanders have private health insurance, accounting for approximately 6 percent of total health care expenditures. 101The British Health Care System

Cost-sharing There are relatively few cost-sharing arrangements for covered services. For example, drugs prescribed by family doctors are subject to a prescription charge, but many patients are exempt. Dentistry services are subject to copayments. Out-of-pocket payments account for 8 percent of health expenditures.

How are revenues generated?

National Health Service (NHS) The NHS is administered by the NHS Executive, Department of Health, and by the Health Authorities. In 1997, the new government shifted from the internal market to integrated care, partnership, and long-term service agreements between providers and commissioners. More recent policy developments include an expansion of patient choice and a move to case-mix reimbursement of hospitals. The NHS, which is funded by a mixture of general taxation and national insurance contributions, accounts for 88 percent of health expenditures.

Private insurance Mix of for-profit and not-for-profit insurers covers private medical care, which plays a complementary role to the NHS. Private insurance offers choice of specialists, avoidance of queues for elective surgery, and higher standards of comfort and privacy than the NHS. Private insurance covers 12 percent of the population and accounts for 4 percent of health expenditures.

How is the delivery system organized? Physicians General practitioners (GPs) act as gatekeepers and are brought together in Primary Care Trusts (PCTs), with budgets for most of the care of their enrolled population and responsibility for the provision of primary and community services. Most GPs are paid directly by the government through a combination of methods salary, capitation, and fee-for-service. Some, however, are employed locally and a new GP contract will introduce greater use of local contracting and introduce quality incentives. Private providers set their own fee-for-service rates but are not generally reimbursed by the public system. Hospitals Mainly semi-autonomous, self-governing public trusts that contract with PCTs. Recently, some routine elective surgery has been procured for NHS patients from purpose-built Treatment Centers, which may be owned and staffed by private sector health care providers. Consultants (i.e., specialist physicians) work mainly in NHS Trust hospitals but may supplement their salary by treating private patients. Government Responsibility for health legislation and general policy matters rests with Parliament at Westminster and in Scotland and with the Assemblies in Wales and Northern Ireland. How are costs controlled? The government sets the budget for the NHS on a three-year cycle. To control utilization and costs, the United Kingdom has controlled physician training, capital expenditure, pay, and PCT revenue budgets. There are also waiting lists. In addition, a centralized administrative system results in lower overhead costs. Other mechanisms contributing to improved value include arrangements for the systematic appraisal of new technologies (i.e., the National Institute for Clinical Excellence) and for monitoring the quality of care delivered (i.e, the Healthcare Commission). 102The United States Health Care System

Who is covered?

Public and private health insurance covers 84 percent of the population. In 2004, 45.8 million were uninsured.

What is covered?

Services Benefit packages vary according to type of insurance, but often include inpatient and outpatient hospital care and physician services. Many also include preventive services, dental care, and prescription drug coverage.

Medicare Social insurance program for the elderly, some of the disabled under age 65, and those with end-stage renal disease. Administered by the federal government, Medicare covers 14 percent of the population. The program is financed through a combination of payroll taxes, general federal revenues, and premiums. It accounts for 17 percent of total health expenditures. Beginning January 2006, Medicare will be expanded to cover outpatient prescription drugs.

Medicaid Joint federal-state health insurance program covering certain groups of the poor. Medicaid also covers nursing home and home health care and is a critical source of coverage for frail elderly and the disabled. Medicaid is administered by the states, which operate within broad federal guidelines. It covers 13 percent of the population and accounts for 16 percent of total health expenditures.

Private Insurance Provided by more than 1,200 not-for-profit and for-profit health insurance companies regulated by state insurance commissioners. Private health insurance can be purchased by

individuals, or it can be funded by voluntary premium contributions shared by employers and employees on a negotiable basis. Private insurance covers 68 percent of the population, including individuals covered by both public and private insurance. It accounts for 36 percent of total health expenditures. Others Private and public funds account for 18 percent of expenditures. How is the delivery system organized? Physicians General practitioners have no formal gatekeeper function, except within some managed care plans. The majorit

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For a small fee you can get the industry's best online privacy or publicly promote your presentations and slide shows with top rankings. But aside from that it's free. We'll even convert your presentations and slide shows into the universal Flash format with all their original multimedia glory, including animation, 2D and 3D transition effects, embedded music or other audio, or even video embedded in slides. All for free. Most of the presentations and slideshows on PowerShow.com are free to view, many are even free to download. (You can choose whether to allow people to download your original PowerPoint presentations and photo slideshows for a fee or free or not at all.) Check out PowerShow.com today - for FREE. There is truly something for everyone!